NUR 302 Module 5 Clinical Judgment Analysis Example

Three Days After the Cabinet Door: A Clinical Judgment Analysis of New Headache in an Older Adult Taking Warfarin

[Student Name]

Southern New Hampshire University

NUR 302: Clinical Judgment and Holistic Assessment in Nursing

Module Five Clinical Judgment Analysis

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

Three Days After the Cabinet Door: A Clinical Judgment Analysis of New Headache in an Older Adult Taking Warfarin

Clinical judgment is easiest to see in cases where the first explanation is the wrong one. This paper analyzes a home health visit in which a composite patient, Mrs. K., an 81-year-old woman taking warfarin, described a headache that she and her family attributed to poor sleep. The analysis is organized by the NCSBN clinical judgment model, whose six steps, as Dickison et al. (2019) lay them out, begin when the nurse notices something and works out what it might mean, continue as competing explanations are weighed and responses chosen, and end with an action whose result is then checked. The case shows that the decisive step was not a sophisticated assessment but a refusal to let a benign explanation close the question while a dangerous one remained possible.

Recognizing Cues

Mrs. K. lives with her daughter and receives home health nursing for wound care on her lower leg. She has atrial fibrillation and takes warfarin, with a target international normalized ratio (INR) of 2.0 to 3.0. At the start of the visit she said she had a headache that had lasted two days and that she was tired. While the nurse was preparing the dressing, the daughter mentioned that her mother had slipped in the kitchen three days earlier and struck her forehead on an open cabinet door, but had not wanted to go to the emergency department because she felt fine afterward. The daughter added that her mother had asked twice that morning whether the nurse was coming.

The relevant cues were therefore a head strike on an anticoagulant, a new headache beginning after the fall, increased fatigue and a subtle change in memory noticed by someone who knows her well. The nurse checked vital signs: blood pressure 164/90, compared with her usual readings in the 130s, and an irregular pulse of 80. A point-of-care INR was 3.6. Her pupils were equal and reactive. She knew who she was and where she was, yet she could not give the date, which she had answered easily at the previous visit. When asked to hold her arms out with eyes closed, her right hand drifted slightly downward.

Analyzing Cues

Taken one at a time, each cue has an ordinary explanation. Headaches are common, fatigue is common in older adults, and elevated blood pressure can follow pain or poor sleep. The analysis changes when the cues are clustered. The fall, the anticoagulant, the supratherapeutic INR, the new headache and the new disorientation all point toward the same organ. Chronic and subacute subdural hematomas are especially common in older adults and can follow a minor head injury, with symptoms that develop over days rather than minutes (Kolias et al., 2014). The mild arm drift is a focal finding, which makes a purely systemic cause, such as infection or dehydration, less likely to explain everything on its own.

Prioritizing Hypotheses

Three explanations were considered. The first was a subdural hematoma or other intracranial bleed after the fall. The second was delirium from a urinary tract infection, which is common in older women and can cause confusion and fatigue. The third was that she was tired and slept badly, as the family believed. The nurse ranked the intracranial bleed first, not because it was certain but because it was the explanation with the most severe consequence if missed and the one most consistent with the focal sign and the anticoagulation. A urinary infection remained possible and could be tested later; missing a bleed could not be undone.

The evidence on delayed bleeding supports caution here rather than reassurance. Chauny et al. (2016) pooled seven studies of anticoagulated patients who had a normal first head CT after trauma and found that about 0.6% had a bleed on a repeat scan 24 hours later. That low figure applies to people who were scanned and had normal results; Mrs. K. was never scanned. The same authors also advised special care for patients showing neurological deterioration or excessive anticoagulation, and Mrs. K. had both.

Generating Solutions and Taking Action

The goal was to get Mrs. K. to imaging and specialist care quickly and safely. The nurse called emergency medical services rather than asking the daughter to drive, because a patient with a possible expanding bleed can deteriorate on the way. While waiting, the nurse kept Mrs. K. seated and observed her, checked her pupils and speech again, made sure she received no aspirin or other medication, and asked the daughter to bring the warfarin bottle and medication list. The nurse then called the primary care provider with an SBAR report: an 81-year-old on warfarin, INR 3.6, fall with head strike three days ago, new headache, new disorientation to date, blood pressure 164/90 and slight right arm drift, transported by ambulance for evaluation of a possible intracranial bleed. The warfarin dose due that evening was held pending the emergency team's decision.

Guidance on bleeding in patients taking oral anticoagulants treats an intracranial hemorrhage as a critical-site bleed that calls for rapid assessment and consideration of reversal (Tomaselli et al., 2020). Those decisions belong to the emergency team, but the nurse's actions determined how fast the team received the information it needed.

Evaluating Outcomes

In the emergency department, a head CT showed a small subacute subdural hematoma on the left side. Her anticoagulation was reversed, and she was admitted for neurological observation. She did not need surgery, her orientation returned to baseline within two days, and the arm drift resolved. The team later reviewed whether her warfarin should be continued and arranged a home safety evaluation. Judged against the goal of the visit, the outcome was good: the bleed was found while it was small, before a larger deterioration. Judged against earlier opportunities, it was also a reminder that the fall three days before had been a missed chance. The nurse added fall reporting to the family teaching and asked the agency to include an explicit question about falls and head strikes at every visit for patients on anticoagulants.

Conclusion

Every cue in this case could have been explained away, and the family had already done so. Clinical judgment consisted of clustering the cues, ranking the hypotheses by what would happen if each were missed and acting on the most dangerous possibility while the less dangerous ones waited. The NCSBN model made that reasoning visible step by step, which is also what makes it teachable.

References

Chauny, J.-M., Marquis, M., Bernard, F., Williamson, D., Albert, M., Laroche, M., & Daoust, R. (2016). Risk of delayed intracranial hemorrhage in anticoagulated patients with mild traumatic brain injury: Systematic review and meta-analysis. The Journal of Emergency Medicine, 51(5), 519-528. https://doi.org/10.1016/j.jemermed.2016.05.045

Dickison, P., Haerling, K. A., & Lasater, K. (2019). Integrating the National Council of State Boards of Nursing Clinical Judgment Model into nursing educational frameworks. Journal of Nursing Education, 58(2), 72-78. https://doi.org/10.3928/01484834-20190122-03

Kolias, A. G., Chari, A., Santarius, T., & Hutchinson, P. J. (2014). Chronic subdural haematoma: Modern management and emerging therapies. Nature Reviews Neurology, 10(10), 570-578. https://doi.org/10.1038/nrneurol.2014.163

Tomaselli, G. F., Mahaffey, K. W., Cuker, A., Dobesh, P. P., Doherty, J. U., Eikelboom, J. W., Florido, R., Gluckman, T. J., Hucker, W. J., Mehran, R., Messé, S. R., Perino, A. C., Rodriguez, F., Sarode, R., Siegal, D. M., & Wiggins, B. S. (2020). 2020 ACC expert consensus decision pathway on management of bleeding in patients on oral anticoagulants. Journal of the American College of Cardiology, 76(5), 594-622. https://doi.org/10.1016/j.jacc.2020.04.053